UMMS Affiliation

Department of Population and Quantitative Health Sciences; Department of Medicine, Division of Cardiovascular Medicine

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Document Type



Cardiology | Cardiovascular Diseases | Health Services Administration | Health Services Research | Military and Veterans Studies | Pharmaceutical Preparations


Background: Direct acting oral anticoagulants (DOACs) theoretically could contribute to addressing underuse of anticoagulation in non-valvular atrial fibrillation (NVAF). Few studies have examined this prospect, however. The potential of DOACs to address underuse of anticoagulation in NVAF could be magnified within a healthcare system that sharply limits patients' exposure to out-of-pocket copayments, such as the Veterans Health Administration (VA).

Methods and Results: We used a clinical data set of all patients with NVAF treated within VA from 2007 to 2016 (n=987 373). We examined how the proportion of patients receiving any anticoagulation, and which agent was prescribed, changed over time. When first approved for VA use in 2011, DOACs constituted a tiny proportion of all prescriptions for anticoagulants (2%); by 2016, this proportion had increased to 45% of all prescriptions and 67% of new prescriptions. Patient characteristics associated with receiving a DOAC, rather than warfarin, included white race, better kidney function, fewer comorbid conditions overall, and no history of stroke or bleeding. In 2007, before the introduction of DOACs, 56% of VA patients with NVAF were receiving anticoagulation; this dipped to 44% in 2012 just after the introduction of DOACs and had risen back to 51% by 2016.

Conclusions: These results do not suggest that the availability of DOACs has led to an increased proportion of patients with NVAF receiving anticoagulation, even in the context of a healthcare system that sharply limits patients' exposure to out-of-pocket copayments.


anticoagulation, atrial fibrillation, practice variation, stroke prevention, veterans

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Copyright 2019: The Authors and RAND Corporation. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

DOI of Published Version



J Am Heart Assoc. 2019 Sep 3;8(17):e012646. doi: 10.1161/JAHA.119.012646. Epub 2019 Aug 23. Link to article on publisher's site

Journal/Book/Conference Title

Journal of the American Heart Association

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Creative Commons License

Creative Commons Attribution-Noncommercial 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License